Upper limb and hand function training and FES (v no intervention) on hand function in people with tetraplegia | SCI Physiotherapy Clinical Practice Guidelines

	Upper limb and hand function training and FES (v no intervention) on hand function in people with tetraplegia
P	People with tetraplegia	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.		Weak opinion statement FOR Upper limb and hand function training and FES may be provided to improve hand function in people with tetraplegia.
I	Upper limb and hand function training and FES
C	No intervention	Consensus-based opinion statement Weak for (96%)
O	Upper limb and hand function	Consensus-based opinion statement Weak for (96%)
	SUMMARY	2 RCTs		Standardised mean difference (95% CI) 0.2 (-0.3 to 0.8) Favours hand training with FES
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency No serious	Imprecision Very serious	Indirectness No serious	Publication bias Serious

UPPER LIMB AND HAND FUNCTION TRAINING PLUS FES ON UPPER LIMB AND HAND FUNCTION: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

UPPER LIMB AND HAND FUNCTION TRAINING PLUS FES ON UPPER LIMB AND HAND FUNCTION: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
HARVEY 2017	Hand training plus FES (plus usual care) V Usual care	1 hour per day, 5 days per week for 8 weeks.	C2-T1 tetraplegia	35/31	Action Research Arm Test (ARAT)	Low Risk of Bias PEDro = 8/10
HOFFMAN 2013	Hand training plus FES V No intervention	5 x per week, 2 hours per day, for 3 weeks.	Chronic tetraplegia	10/9	Jebsen Hand function test	High Risk of Bias PEDro = 3/10

The Australian and NZ SCI Physiotherapy guideline committee recommends upper limb and hand function training and FES to improve hand function in people with tetraplegia.

This is a consensus-based opinion statement supported by the opinions of the experts even though there is one randomised controlled trial related to this topic. However, the result of this randomised controlled trial is inconclusive preventing an evidence recommendation. The guideline states:

Upper limb and hand function training and FES may be provided to improve hand function in people with tetraplegia.

This statement was formed by considering the opinions of the experts alongside other factors. The other factors that were considered were benefits and harms, values and preferences, resource use, equity, accessibility, and feasibility. The results of one randomised controlled trial was also taken into consideration. This is a consensus-based opinion statement. Consensus-based opinion statements are less robust than evidence-based recommendations. They can be strong or weak.

This is a strong consensus-based opinion statement which means that the guideline panel is confident they can recommend upper limb and hand function training and FES to improve hand function in people with tetraplegia based on opinion.

To learn more about the research related to this intervention go to the research summary.

Hoffman L F-FE. Effects of practice combined with somatosensory or motor stimulation on hand function in persons with spinal Cord Injury. Topics in spinal cord injury rehabilitation 2013; 19: 288.
Harvey LA, Dunlop SA, Churilov L, et al. Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury ('Hands On'): a randomised trial. Journal of physiotherapy 2017; 63: 197-204.